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REMARKS
0 N
VESICO-VAGINAL FISTULE,
WITH AN ACCOUNT OF A
NEW MODE OF SUTURE,
AND
SEVEN SUCCESSFUL OPERATIONS.
BY N. BOZEMAN, M. D. ,
OP MONTGOMERY, ALA.
LOUISVILLE:
HULL fc BROTHER, MAIN STREET, NEAR FOURTH.
18 5 6.
WP
VESICO-VAGINAL FISTULE.
[From the Louisville Review.]
It would appear, from the silence of the older authors in regard
to vesico-vaginal fistule, that it was a subject to which they paid
little or no attention. But it would not be a fair inference from
this circumstance, that the affection did not exist, or that its sub-
jects did not apply for medical or surgical aid. The practice of
obstetrics was less well understood then than at present; and it is
reasonable to suppose that accidents resulting in fistule were com-
paratively more frequent. Surgeons must, therefore, at a very
early period, have known something about it; but, being unable to
afford the necessary relief, they probably supposed that it would
be a waste of words to record anything upon the subject. And,
indeed, in turning to the written experience of more modern sur-
geons, we find that no advance was made toward the proper under-
standing and treatment of the disease until within the last quarter
of a century. It is true, that previous to that time, it had been
repeatedly described, and several methods of treatment had been
proposed; but the profession manifested but little interest in the
former, and the latter proved beneficial only in a very few cases.
Now, however, there is no subject in surgery with the pathology
and symptomatology of which we are better acquainted; and, as I
hope to show in the few following pages, there is no disease of
equal severity that is more amenable to operative procedure. But,
before entering upon the subject, I shall premise a few anatomical
considerations, which seem to me necessary to its proper under-
standing.
Anatomy.—The base of the bladder, as is well known, rests
upon the anterior wall of the vagina, a small quantity of connect-
ing areolar tissue alone intervening. The union of the two con-
stitutes what is called the Vesico-Vaginal Septum, which is com-
76
Original Communications.
posed, therefore, of muscular and erectile tissue, covered upon
both surfaces by mucous membrane. The shape of this septum,
/". e., the outline of the union of the two walls, resembles, some-
what, the heart upon playing cards, its base presenting upward,
the neck of the uterus occupying the notch, and the apex downward
and forward, toward the commencement of the urethra. Its area
comprises, usually, about four square inches; and it may be stated
here, that a clear knowledge of its shape and extent is oftentimes
of the utmost importance in a surgical point of view; for, imme-
diately outside of the limits mentioned, the surfaces of the vagina
and bladder are invested with peritoneum, and any operation in
volving this structure is of course attended with additional risk.
Situation, Size, 8fe.—The most common situation of the opening
constituting vesico-vaginal fistule is usually about the centre of
the vesico-vaginal septum; but it may occur at any point: I have
met with cases in which it seemed to occupy the extreme border
of the septum. The size of the orifice may be no larger than
barely to admit a tolerably large probe; but instances are on
record in which the whole septum had sloughed away, thus leaving
a chasm of enormous dimensions, through which the superior fundus
of the bladder protruded, and made its appearance at the vulva,
in the form of a large, fleshy-looking tumor. The shape of the
fistulous opening is as various as its size and situation, but may be
stated, as a general rule, to be oval from above downward, although
the long axis is not unfrequently oblique or even transverse in its
direction. The number varies from one to several; but I have
never met with more than two. Of ten cases that have come under
my observation, four were of the double variety, and the remainder
single.
The presence of more than one fistule is a circumstance of con-
siderable importance in reference to the chances of successful ope-
ration, as I shall presently attempt to show, and it is not a little
surprising that writers upon the subject have so entirely overlooked
this not uncommon complication. It is in cases of this kind that
the method of operation which I am about to propose possesses, in
my judgment, an advantage unequalled by any procedure hereto-
fore invented.
The common causes of vesico-vaginal fistule are impaction of
Vesico-Vaginal Fistule. 77
the child's head in the pelvis in protracted labors, and the misuse
of forceps in instrumental deliveries; the vesico-vagnial septum in
either case being so much injured as to fall into a siate of mortifi-
cation, involving a smaller or larger part of its extent. It is also
an occasional result of lithotomy performed through the vagina;
of malignant disease of the neck of the uterus, and of ulceration
produced by the presence of a foreign body in the bladder or
vagina. Mr. Brown, of London, reports a case which was occa-
sioned by the combined presence of a calculus in the bladder, and
the occurrence of parturition.
The symptoms of the disease are few, but well marked. Drib-
ling of urine from the back part of the vulva coming on within
a few days after labor, and producing excoriation of the nates and
thighs, with an inability to empty the bladder in the natural
way are usually conclusive; but, if any doubt should exist, a
resort to a digital or specular examination will readily place the
diagnosis upon a positive footing.
The prognosis, formerly pronounced to be unfavorable in all
cases, may be now stated to be favorable in the great majority—
a change which, considering the loathsome and disgusting nature
of the malady, cannot but inspire the heart of every truly philan-
thropic surgeon with just and unbounded pride in his beneficent
and noble calling.
Treatment.—Until within a few years past, so uniformly un-
satisfactory were the results of the treatment of vesico-vaginal
fistule, that many surgeons entirely despaired of ever being able
to offer the poor afflicted subjects of this malady any hope what-
ever of permanent relief. But still, from time to time various
plans were proposed, some of which proved more or less bene-
ficial, and others again entirely useless. Among the former was
cauterization with the hot iron, which having produced a few
permanent cures, and mitigated many cases, was a step consider-
ably in advance of the old practice of pronouncing all cases in-
curable. Indeed, this operation is still viewed by many otherwise
intelligent surgeons, especially in Europe, as almost the only
hope of relief. Among its most strenuous advocates may be men-
tioned M. Dupuytren and Mr. Liston, who, although now dead,
are nevertheless considered as the representatives of modern sur-
78
Original Communications.
gery in the respective countries to which they belonged. That
the actual cautery has done much good in many cases oannot
be denied; but so uncertain a procedure, even in the hands of
such men as the two just mentioned, justly claims bu'- a minor
consideration in the estimate of those who are fully acquainted
with the present resources of the chirurgical art.
Succeeding the actual cautery, came the suture, which is said to
have been proposed for the relief of the disease about the middle
of the seventeenth century by a Dutch surgeon by the name of
Roonhuysen. The practise was afterwards adopted by Fatio and
Voelter, but with what success we are not informed; but it cer-
tainly could not have been very encouraging, as it soon fell into
disuse. About the beginning of the present century, however, the
suture was revived and, variously modified, has formed the basis
of almost every successful mode of treatment that has been prac-
tised both in Europe and this country.
In Germany different modes of employing the suture have been
from time to time adopted. Wutzer and Dieffenbach are said to
have practised it with the most success. The former is stated by
Chelius to have advanced considerably farther than his prede-
cessors by conjoining puncture of the bladder for the purpose of
keeping this organ empty, and thus preventing the contact of the
urine with the parts under operation. Little or no improvement,
I apprehend, has been made upon the operation of these surgeons
by their countrymen, judging from the recent procedures of Roser,
Simon, Teuner and Boeck.*
In France the suture has undergone many ingenious modifica-
tions for the purpose of rendering it more efficient in the treatment
of the affection under consideration, and for some of them con-
siderable success is claimed. An account of them, however, would
much trausgress the limits of this paper, and prove at best more
curious than useful. Of their general success and the estimate in
which they are held, some idea may be had from the following re-
marks of Velpeau : " The suture, which must have first suggested
itself to the mind, is of such difficult application that but few
practitioners have ventured to make trial of it, so that scarcely
* Amer. Med. Moathly, Aug., 1855.
Vesico-Vaginal Fistule.
79
any mention is made of it in the works which have issued from
the school of Paris. To abrade the borders of an opening when
We do not know where to grasp them, to shut it up by means of
needles or thread when we have no point apparently to secure
them, to act upon a moveable partition placed between two cavities
hidden from our sight, and upon which we can scarcely find any
purchase, has appeared to be calculated to have no other result
than to cause unnecessary suffering to the patient."*
Such is the opinion of the erudite and accomplished surgeon of
the Hopital de la Charite, an opinion derived doubtless from a
careful consideration of all the operative procedures that have been
suggested or tried in France, Germany, and Great Britain. And
the statement of his distinguished cotemporary M. Vidal (de
Cassis) is not less discouraging. His words are r " I do not believe
that there exists in the science of surgery a well-authenticated
complete cure of vesico-vaginal fistule, a fistule due to a loss of
substance from the bas-fond of the bladder."t Of the success of the
autoplastic operations devised and practiced by Jobert and Gerdy,
we have no positive information. The former surgeon also operates
with the suture, and there is reason to believe that he has met
with much more encouraging results than any of his European
brethern.
Turning now to Great Britain, what do we find, has been
accomplished there in the treatment of vesico-vaginal fistule 1
London surgeons, with all their hospital advantages, until
within a very few years past, gave this subject little or no
attention. Neither Sir Charles Bell, Sir Astley Cooper, nor Mr.
Samuel Cooper have so much as alluded to it, either in their
writings or lectures. Mr. Robert Liston devotes to it but one
paragraph, and, as it appears, attached more importance to what
could not rather than what could be done by the surgeon. " At-
tempts," says he, "have been made to close the aperture by
paring the edges, and then inserting sutures; but this is a pro-
ceeding both difficult in execution, and not likely to prove success-
ful. The thinness of the parts, the presence of a secreting surface
on each side, and the oozing of acrid urine betwixt the edges, all
* Operative Surgery, Vol. 3. t Pathologie Externe. 2nd edit.
80
Original Communications.
militate strongly against adhesion. No benefit can be expected
from any treatment, unless the opening be of no great size; and, in
such cases, the cautery will be found most effectual. * * * *
By the cautery I have succeeded in relieving many, and in curing
a few cases." *
Druitt, in his "Surgeon's Vade-Mecum," devotes to this and
four or five other diseases, together with their treatment, only a
single page. The senior surgeon to Guy's Hospital, Mr. Bransby
B. Cooper, it seems, has no experience at all with its treatment.
He speaks of it as being most difficult of cure: "My colleague,
Dr. Dever," he says, "has had several cases of recto-vaginal and
vesico-vaginal fistule, which he has attempted to obliterate by
plastic operations and sutures, caustics, and the actual cautery.
The result of his experience proves, however, that very few cases
are ever permanently cured, although, by means of the actual
cautery, he has frequently reduced the abnormal opening to the
size of a pin's head; but I believe that only in one or two cases
has he succeeded in producing a permanent cure."t Mr. Erich-
sen says, that urethro-vaginal fistule, when small, may sometimes
be closed by applying the electric cautery or red-hot wire to its
edges, once a fortnight or three weeks; but he further remarks
"when the fistule is large, and especially when vesical, its cure
can be accomplishea only by paring the edges, and bringing them
together with sutures, and thus attempting to procure union by the
first intention. In effecting this, however, two difficulties present
themselves*—the sutures either cutting their way out too*soon, or the
trickling of urine between the freshly-pared edges interfering with
adhesion." Of the various contrivances employed to overcome
these difficulties, he recommends the bead sutures of Mr. Brooks,
and the clamp suture of Dr. J. Marion Sims. "The treatment
recommended by Dr. Sims," he observes "leaves little to be
desired in the management of these cases." J Prof. Pirrie, in his
recent work on surgery, does not even mention the disease or its
treatment. Mr. Brown, surgeon accoucheur to St. Mary's Hospi-
tal, has, within the last few years, gone far ahead of any of his
cotemporaries, in the management of those diseases of the female
* Elemeuts of Surgery. f Lectures ou Surgery. J System of Surgery.
Vesico-Vaginal Fistule.
81
requiring surgical interference. His recent work shows that he
has devoted much time and attention to the subject. Although
his treatment of the disease under consideration has not been very
successful, yet it has been conducted upon enlightened principles.
As an illustration of the difficulties to be met with in any operative
procedure, he gives the details of four cases treated by himself.
Two of these were permanently cured; one, by the actual cautery
and incision; and tht other, by the quill suture. The remaining
two were only partially relieved by the actual cautery and suture
combined. Mr. B. employs the clamp as well as the quill suture.
Having thus briefly glanced at the state of surgical science, in
reference to the disease in question, in Germany, France, and Great
Britain, let us turn to our own country, and see what has been
done there. And here I may state, without the least fear of con-
tradiction, and with no little national pride, that the surgeons of
the United States havt so far outstripped their European brethren
as to place this horrible complaint, which the latter have declared
incurable, upon a par, as regards the probabilities of successful
treatment, with accidents of like severity affecting other parts of
the body.
Drs. Mettauer, of Virginia; Hay ward, of Boston; Pancoast, of
Philadelphia, and J. Marion Sims, late of Montgomery, Alabama,
but now of New York, are the only surgeons in this country, as
far as I am informed, who have paid special attention to the subject
of vesico-vaginal fistule r and, in noticing their respective opera-
tions, it will suit my purpose to speak somewhat in detail concern-
ing the different mode? of closing the fistulous opening,, as herein
lies the superior advantages of one operation over another, as I
shall presently endeavor to show.
Dr. Mettauer operated for the relief of this malady as early as
1830* His method consisted in paring the edges of the fistulous
opening, and maintaining them in contact with interrupted sutures
made of lead wire. These he carried entirely through the vesico-
vaginal septum, at a distance of an inch from the denuded borders
A sufficient number of them having been introduced, the ends of each
wire were separately twisted together until firm coaptation of the
edges was effected. The twisted extremities were afterwards cut off
* Virginia Medical and Surgical Journal.
6
82
Original Communications.
a short distance exterior to the vulva. On the third day the sutures
were tightened by twisting them again; and about the tenth day they
were removed. Such was the original method employed by Dr.
Mettauer, and, with but little if any alteration, is the one he still
practices. He has performed it quite a number of times, and claims
considerable success.
Dr. Hayward, without any knowledge of what had been done by
Dr. Mettauer, performed his first operation in 1839, and published it
the same year.* He has the credit, I believe, of having been the
first to operate successfully in this country; but there is no doubt
that Dr. Mettauer preceded him by several years, although the latter
did not publish his operation until 1847. The peculiarity of Dr.
Hayward's procedure consists in the mode of getting at the parts.
He first introduces into the bladder, through the urethra, a whale-
bone bougie, with which, as a lever, the symphysis pubis serv-
ing as a fulcrum, he next brings down the base of the bladder to
the vulva, aud thereby exposes the fistule fully to view. He then
pares the edges of the openings, and brings them together by the
ordinary interrupted sutures, which, in their introduction, are not
allowed to penetrate the mucous coat of the bladder. The opera-
tion being thus completed, and the bougie removed, the bladder is
permitted to return to its proper place, and the sutures are allowed
to remain until they become detached by ulceration.
This is the method now recommended by Dr. Hayward, although
formerly he was in the habit of splitting the edges of the fistule,
so as to present a more extensive surface for agglutination, and at
the same time lessen the chances of piercing the mucous membrane
of the bladder in introducing the sutures. He also directed the
bladder to be again depressed after a certain number of days, and
the sutures removed. Dr. Hayward has performed his operation
twenty times, but with no very great success, having cured, I
understand, but three cases permanently, t
Dr. Pancoast's method consists in adapting the edges of the
fistule to each other on the principle of the tongue and groove.
The posterior border he splits to the extent of half an inch, and
pares the anterior to the shape of a wedge. The former is then
made to receive the latter. In this way four raw surfaces are
* Am. Journal of Med. Sciences. t Surgical Reports.
Vesico-Vaginal Fistule.
83
brought in contact, and held in this relation by his plastic suture.
How much success Dr. Pancoast has had by this method I am
not prepared to state. He reports, in the Medical Examiner, for
May, 1847, two cases cured in this manner by himself.
Lastly, we come to consider the method of Dr. Sims, a de-
scription of which I deem altogether unnecessary; for, being gen-
erally approved by the profession, it is well understood by every
one interested in such matters. Suffice it to say that the pecu-
liarity, as well as the great advantages of Dr. Sims' method, are
to be found in his clamp suture.
Considering the comparatively small measure of success obtained
by Drs. Mettauer, Hayward, and Pancoast, it would be useless to
enter into a discussion of their relative merits, as I suppose that
no one, in this country at least, will be likely to adopt the method
of any one of these gentlemen, with the great advantages of Dr.
Sims' method staring them in the face. But it is to the latter that
I invite attention, and, however bold or fool-hardy the attempt may
appear, I hope to be able to show that the clamp suture has se-
rious objections that may be entirely obviated by the procedure
presently to be described. In saying this, however, I do not wish
to be understood as attempting to detract from the great credit
due from the profession and the public to Dr. Sims for his untiring
perseverance in bringing his method to its present high state of
perfection. I consider that this gentleman is fully entitled to more
than all the praise that has been bestowed upon him, both in
America and Europe. To the honor of his professional brethren
in this country, it may be stated that no one has been found who
has not gladly accorded to him the high distinction that he at
present occupies. I am sorry that the same cannot be said of
European surgeons in general, for, with the exception of Mr. Erich-
sen, Mr. Brown, and Mr. Druitt, of London, no one on the other
side of the Atlantic has, to my knowledge, proved sufficiently frank
to do full justice to Dr. Sims' claims. Fully impressed, therefore,
with the importance of the position I assume in attempting to show
that the clamp suture is objectionable, I proceed to the task, actu-
ated, as every inquirer after truth should be, by no other motives
than a desire to make facts and principles subservient to the great
ends of science.
84
Original Communications.
In the first place, then, Dr. Sims states that the " (damp suture
lies embedded in the tissues for an indefinite period without danger
of cutting its way out as do silk ligatures." This proposition is
doubtless true, so far as it implies that the clamp suture is much
less liable to cut out than silk ligatures; but the question is,
does not the clamp suture itself irritate and very often cut out?
Dr. Sims says not. My experience with it, however, has led mo
to a different conclusion. I have several times seen it ulcerate out,
and that too within five or six days, thus entirely defeating the
object of its application. When there is much dragging of the
parts, this is almost sure to occur. The liability to this accident
I have found greatly increased by an indurated condition of the
tissues, which very often exists on one or both sides of the fistulous
opening. The ill consequences of the ulceration occasioned by
one or both clamps are sufficiently evident. Other fistules are in
this way liable to be formed, as occurred in a case alluded to by
Dr. Mettauer,* and even if this does not take place, the morbid
action may extend to the raw edges of the opening, and thus inter-
fere with the healing process. Gangrene and sloughing of the
included parts may take place also when the clamps are applied
with too much force.
Another objection to the clamp suture consists in the fact that
to apply it properly requires more experience than most practi-
tioners of surgery can be supposed to possess. The operator must
be able to judge of the condition of the tissues, whether indurated
or not, and whether this condition is confined to one or both sides
of the fistulous opening. If induration exists, he must know what
precautions are to be observed in the arrangement of the clamps,
and the dangers resulting from a neglect of these precautions.
Many failures, I have no doubt, can be referred to a want of fa-
miliar acquaintance with these matters, which, as just stated, is to
be gained only by much experience.
Another, and the greatest objection to Dr. Sims' method, is the
frequent impossibility, incases of double fistule, of applying two sets
of clamps at the same time. This I regard as a consideration of the
utmost importance. If two fistulous openings are found to exist
* Op. Cit.
Vesico-Vaginal Fistule. 85
and circumstances will allow of but one being closed, failure is
almost sure to follow, owing to the escape of urine through the
other into the vagina, and its contact with the denuded edges.
Still another objection is the impossibility of making the sutures
act only in one direction: They have all to be introduced exactly
alike; each wire must be entered on the same line, at a proper
distance from the edge of the fistule, and brought out in a similar
manner, so that when the shot are secured in their places, the
same amount of traction, and in the same direction, shall be exerted
upon each suture. Unless these precautions be observed, the clamp
will not lie easy, and is liable to do injury.
Such I conceive to be most important objections to the clamp
suture. There are others of a minor consideration, but they need
not be mentioned here.
Very soon after I began to employ this suture in the treatment
of vesico-vaginal fistule, I discovered these faults; but it was a
long time before I could believe but that it was the best and surest
plan of procedure that could be adopted. Failure upon failure oc-
curred, when from the favorable nature of the cases such results
were not to be expected. Finally a case of double fistule came under
my care. The two openings were in close proximity, and the long
axis of one was at right angles to that of the other, thus precluding
the possibility of using two sets of clamps at once. Thus circum-
stanced, I adopted the only alternative, which was to close one and
leave the other for a future operation. Accordingly I applied the
clamps to the superior aperture, as the peculiar nature of the parts
required that this one should be closed in order that a resting
place might be formed for one of the clamps in the next operation.
On the tenth day, I found upon examination that the apparatus
had cut out entirely. The failure I decided to be due to the in-
jurious effects of the urine upon the denuded borders of the fistule,
and upon the raw surfaces produced by the pressure of the clamps;
and I became furthermore satisfied that I should never be able to
cure the case, unless I could invent some contrivance by which
either to close both openings at one operation, or to afford com-
plete protection to the denuded edges of one during the healing
process. The thin and raw edges of the. fistule when brought to-
gether by the clamp suture under such circumstances, are neces-
86
Original Communications.
sarily acted upon by the poisonous urine on both the vesical and
vaginal surfaces, union by the first, intention being thereby rendered
very improbable, even under auspices otherwise most favorable, and
in the majority of instances almost clearly impossible. To contrive
an apparatus that would fulfill one or the other of these indications
required, I supposed, much more inventive talent than I possessed ;
and after a little thought, I abandoned all hope of providing any-
thing that would answer the purpose. Sometime afterwards, how-
ever, while buttoning my vest, it occurred to me that a somewhat
similar process might be applied to such cases as the one above
cited, and after turning the matter over in my mind, I determined
to put the idea in practice. Accordingly I made a contrivance on
the'button principle, and applied it in a case where the clamp su-
ture had failed three times. The result was, as it has been in
every trial since, as satisfactory as could be desired.
With such flattering results in its favor, I propose now to offer
the operation to the profession for what it is worth. It will be
found to be simple and easy in its performance, applicable to the
great majority of cases, and devoid of any inconvenience to the
patient. From its construction, mode of action, and the circum-
stances which led to its adoption, I shall call it the Button Suture.
It is, however, only a modification of the twisted, as the clamp is
a modification of the quill suture. After a brief description of the
apparatus, and the mode of applying it, 1 shall add the details of
four successive cases requiring seven operations in which I have
employed it without a single failure.
The essential parts of the apparatus consist of wire for the su-
tures, a metallic button or plate, and perforated shot to retain the
latter in place. The wire should be made of pure silver, about
the size usually marked No. 93, and properly annealed. A length
of about eighteen inches should be allowed for each suture.
The button possesses several peculiarities. It may be made of
either lead or silver. The former, hammered out to the thickness
of 1-lGth of an inch, answers the purpose tolerably well. The latter
can be made still thinner, and does better on several accounts; it is
lighter, less likely to yield under pressure, admits of a higher
polish, and allows the wires to be drawn through the small holes,
without dragging.
Vesico-Vaginal Fistule.
87
Fig. 1.
Full Size. End View
The object of the button is to cover the fistulous opening after
the introduction of the sutures, and its size and shape will therefore
vary somewhat according to circumstances. The shape of those
that I usually employ is oval (fig. 1), but they may be circular,
semi-circular, L or T shaped, to suit individual cases. The size
will also necessarily vary, but it is seldom that one larger than the
largest here represented, say 1 1-4 inches in length and 5-8ths of
an inch in breadth, is required. But whatever the shape or
size, it is a matter of 'great importance that the under surface
should be slightly concave, and the edge turned up. Along the
middle of the button are arranged perforations for the passage
of the sutures, which should be sufficiently large to admit two
thicknesses of the wire freely. The number of these openings will
depend of course upon the number of the sutures, which are usually
placed about 3-16ths of an inch apart.
The shot are No. 3 in size, and perforated for the passage of
the wires.
Operation.—In remarking upon the different operations which
have been performed in this country, I stated that I should con-
fine myself mainly to a consideration of the several modes ofsu-
turization, and, singling out that of Dr. Sims as the only one
deserving of notice, I have attempted to show wherein it is de-
ficient. It is not necessary, nor is it my purpose, to enter into
a detailed account of the earlier steps of the operation; for in re-
gard to these matters Dr. Sims has left little or nothing to be
desired. I must mention however, that I generally bevel the
edges of the fistule upon the vaginal aspect to a greater extent
than is recommended for the clamp suture. The object of this
is to obtain large surfaces for agglutination, and at the same
time to admit of a sufficiently firm degree of approximation to
prevent if possible the least passage of urine through the part.
sS
Original Communications.
The edges of the fistule having been pared, the wire sutures
are to be lodged in their respective places in the usual way, by
attaching them to the ends of silk ligatures previously carried by
means of a needle through the septum from one side of the fistule
to the other. But in connection with this step of the operation,
there is some difference between Dr. Suns procedure and my
own. In the first place, I do not usually take so firm a hold of
the tissues, the space between the entrance of the needle and the
edge of the fistule rarely if ever exceeding half an inch, and it
matters not whether the parts be indurated or not, the wire is
not likely to cut out very soon. Secondly, it is not necessary
to observe the same scrupulous care in entering and bringing out
the sutures upon an exact line with each other; for, as will be
hereafter understood, each one is in its action entirely independent
of the others. Thirdly, instead of being obliged always to place
the sutures parallel with each other, I have it in my power, if the
peculiar nature of the case indicate, to insert them in any direc-
tion, and am thus enabled to bring within the sphere of successful
treatment a large class of eases, which, owing to the irregular
shape of the fistule, and the scarcity of tissue not admitting of
extensive paring, cannot be subjected to the clamp suture.
In regard to the needle for passing the ligature, there is great
diversity of opinion. Nearly every operator has one to suit his
own peculiar fancy, and probably uses it, after some little experience,
to better advantage than he could any other. M. Jobert recom-
mends the spear-pointed spring canula of Lewziski. Dr. Druitt
prefers the fish hook needle, and some surgeons employ the or-
dinary short curved variety. I am myself in the habit of using
one that is short, straight, and spear-pointed, as represented in
fig. 2, a, b, c.d, the length varying from a half to three fourths of
an inch.
The needle-holder or clasp may be straight (fig. 2, e) as recom-
mended by Dr. Sims, Mr. Brown, of London, and others, or it may
be made of the shape represented at o. The latter was made at my
own suggestion, and I have found it to answer a better pur-
pose than the straight variety where the fistule is situated far to
one side or the other. It consists simply of the ordinary steel
clasp (h) having a long substantial shaft and a flexible metallic
Vesico-Vaginal Fistule.
89
Flg*2- canula (k) for the purpose of ap-
proximating the branches of the
clasp. The latter are furrowed
in various directions for the pur-
pose of holding the needle firmly,
and allowing it to be placed at
any angle that may be desired.
(At l may be seen a needle clasp-
ed and ready for use.)
The introduction of the needle
in reference to the structures to
be penetrated, is justly considered
a matter of no little importance.
Dr. Mettauer and some others
advise that the instrument be car-
ried entirely through the vesico-
vaginal septum. Drs. Sims and
Hayward strongly disapprove of
this practice on the ground that
other fistules may thus be pro-
duced; and I fully agree with
them. Indeed, I consider that
too much care cannot be taken to
avoid piercing the mucous coat of
the bladder; and the needle, in-
stead therefore of being carried
through the septum, should be
brought out at at the edge of the
opening in the vesical sub-mucous
areolar tissue.
As heretofore mentioned, the
wire for each suture should be
about eighteen inches in length, and the sutures should be placed
usually not more than 3-16ths of an inch apart, although if the tissue
be sufficiently abundant to admit of easy approximation without
dragging, an interval of l-4th of an inch may be left.
90
Original Communications.
«g. s. Figure 3 is a representation of a
fistule of the most common shape,
with its edges pared in the bevel-
led manner heretofore mentioned,
and the silver wires drawn through.
The next step in the operation is
to draw the raw edges closely in
contact, by bringing the opposite
ends of each wire together. This
may be readily accomplished with
an instrument which I have invented for the purpose, and call the
suture adjuster. It consists simply of a steel rod,
A...A fixed in an ordinary handle, its distal extremity
flattened, perforated, and raised upon one side into
a kind of knob as represented at A. The opposite
ends of each suture are to be passed through the
aperture in the end of the adjuster from the convex
toward the flat surface, and while the former are
held firmly between the forefinger and thumb of the
left hand, the latter is carefully slipped down upon
the wires until it comes closely in contact with the
tissues. In this way the edges of the fistule are gently
forced together, and, for the time being, the stiffness
of the wire prevents their separation. Should it be
found, however, that accurate coaptation does not
take place, owing to the imperfect manner in which
the edges have been pared, the sutures may be read-
ily loosened, and the defect remedied without the
necessity of withdrawing the wires. The appear-
ance of the parts, after all the sutures have been ad-
justed, is faithfully represented in figure 5.
A button of suitable
shape and size having
been previously provid- f f 1
ed, is now to be placed ^^l^^^^"^
upon the wires, (fig. 6) -^"f^**^^
its concave surface cor-
responding to the vesico-vaginal septum, and carried
^%^
Vesico-Vaginal Fistule.
91
Fig. 8.
Fig. 7.
down in contact with the septum.
The wires being again held in the
left hand, the button should be
pressed gently against and adapt-
ed to the surface of the parts (fig.
7). This may be accomplished
by an instrument which I call
the hutton adjuster, represented at
figure 8, consisting of a stiff iron
rod, bent at a right angle within
half an inch of its distal extrem-
ity, and inserted into an ordinary
wooden handle.
The shot are to be now passed down over the ap-
proximated ends of each suture (fig. 9) to the convex
surface of the button, and here each one is to be suc-
cessively grasped with a pair of strong forceps, (such
as is represented at figure 10,) and held against the
button, while traction is made upon the corresponding
suture, in order to bring the vaginal surface of the
septum in close contact with the concave surface of
the button, and insure close coaptation of the edges of
the fistule. This having been satisfactorily accom-
plished, sufficient force is exerted upon the forceps to
compress the shot, and thus prevent its slipping. The
operation is then concluded by clipping off the wires
close to the shot, as seen at figure 11. The apparatus
is allowed to remain on, generally, not more than ten
days.
Remarks.—After the foregoing description of the
construction and application of the button suture, it is
unnecessary that I
should add any thing
by way of explaining
its modus operandi.
Its principle, as here-
tofore stated, is found-
ed upon and is anala-
Fig. 9.
92
Original Communications.
Fi3. 10.
gous to that by which the vest Fi«. n
or other clothing is ordinarily
fastened. The only marked
difference is, that in the latter
process the button is first se-
cured to the vest, and then the two sides brought
together; while in the former the process is re-
versed, the opposite edges of the opening to be
closed being brought together, and then the
button put on.
One of the marked peculiarities of the button
suture is the separate and independent action of
each wire, as a consequence of which, as before
stated, it is not necessary that the separate points
should be parallel with each other, but may be
placed in any direction, even at right angles, if the
shape of the fistule should require it. The only
[precaution requisite is to have the shape of the
button made to correspond to that of the fistule,
and its perforations to the arrangement of the
points of suture. Another advantage derived
from this circumstance consists in the fact that
if too much force he applied to one suture in
drawing the edges of the fistule together, no injury results in con-
sequence to the others, and such an accident as sloughing is hardly
to be thought of.
By means of the button suture quietude and an accuracy of ap-
proximation are secured to a greater degree than by any apparatus
that has ever before been invented, two circumstances upon which
the cure of fistules oftentimes solely depends. Splints properly
adapted to the arm in transverse fracture of the humerus do not hold
the fractured ends of the bone so accurately in apposition as does
the button suture the edges of the fistule. But, unlike splints
applied to the limbs, there is little or no outside pressure upon the
approximated edges of the fistule, for, by the concave form of the
under surface of the button, the pressure is thrown some distance
off, and any injury that might result from this circumstance is
entirely obviated.
Vesico-Vaginal Fistule.
93
But probably one of the most important advantages of the but-
ton suture is the protection that it affords to the denuded edges of
the fistule. It is a fact well known to surgeons, that a simple in-
cised wound will heal with much more rapidity when shielded from
the atmosphere and all other extraneous influences, than, all other
circumstances being equally favorable, when there is no such pro-
tection. Vesico-vaginal fistule, after the edges have been pared,
being truly an incised wound, is subject, of course, to the same
general laws. The button fulfills this indication of protection with
positive certainty, if its application be properly attended to. It is
true that in a deep cavity like the vagina, the opposite walls of
which are nearly always in contact, the atmosphere can have little
or no effect upon the affected parts. But there are other and far
more obnoxious influences to shut out; and of these the urine, in
cases of double fistule, is most hurtful, for, as it is not commonly
the case that both openings are closed at the same operation, the
one first operated on, without some protection, is continually bathed
in this poisonous fluid. I say poisonous, for few will deny to urine
s«ch an influence upon raw surfaces, and the consequence is that
failure from this circumstance alone oftentimes occurs. Leucorrhoeal
discharges are also more or less harmful, a fact of which Chelius
was aware, but I do not know that any other author has made
mention of it.
Summary.—My experience with the button suture, as detailed
in the history of the seven operations appended to this paper, has, I
think, established its superiority to the clamp suture in the follow-
ing particulars:
1st. It is simpler in its construction, and applicable to a greater
number of cases.
2d. It affords complete protection and perfect rest to the approx-
imated edges of the fistule.
3d. If two fistulous openings exist, one or both may be closed
at the same sitting, according to the inclination of the operator or
patient, without reference to the condition of the parts.
4th. The introduction of the sutures does not demand the same
exactness in regard to the position of the points.
5th. The independent action of each suture renders parallelism
unnecessary, and thus gives the operator the liberty of introducing
them in whatever direction may best suit his purpose.
94
Original Communications.
6th. If perfect coaptation be found wanting after the edges of
the fistule have been brought together, it is not necessary to re-
move the sutures, but simply to loosen them in order to perfect
the paring.
7th. The apparatus does not irritate, it matters not what the
condition of the parts may be, provided they are not in a state of
progressive ulceration or inflammation.
8th. The apparatus requires to remain in position seldom longer
than ten days.
Having thus completed an imperfect account of the construction
of the button suture, and attempted to establish for it the first
place among similar contrivances for the treatment of vesico-vagi-
nal fistule in the estimate of the profession, I shall conclude this
paper by an account of all the cases in which it has been employed,
subjoining a simple statement of its success in comparison with
that of other procedures.
Case I. — Vesico- Vaginal Fistule of nearly three years standing;
failure of three operations with the Clamp Suture ; one operation with
the Button Suture entirely successful.
The patient was a young colored girl of small stature and delicate consti-
tution. She w;is confined with her first and only child, August, 1852,
and states that she was in labor about forty hours; the child, which was
large, having to bo eventually removed with instruments. Several days
after delivery, dribbling of urine occurred from the vagina, which con-
tinuing, together with other indisposition, confined her to bed for five
or six months. The following spring she was operated upon according
to the method of Dr. Sims', but was not relieved. She came under my
charge a short time afterwards, and upon examination, I readily dis-
covered a circular opening about the size of a No. 6 catheter, occupying
the vesico-vaginal septum near the neck of the uterus and a little to
the left side. On the right side the tissues were in a normal condition,
but on the left very much indurated. After due preparation of the
system, I applied the clamp suture in the usual way. On the thirteenth
day, I examined and found that the clamp on the left side had cut en-
tirely out, and the aperture considerably enlarged.
Shortly after this unsuccessful operation, the patient's general health
became very much impaired, and it was thought advisable to allow her
to return home. I heard no more of the case until April of 1855, when
she was again placed under my care, having, in the meantime, entirely
Vesico-Vaginal Fistule.
95
regained her usual good health. I found on making an examination,
that the fistule was somewhat smaller than when I last saw her, but the
induration of the left border still existed. Aside from this latter cir-
cumstance, I considered the case altogether favorable and felt very
confident that an operation would prove successful. Accordingly, on
the 12th of April, I applied the clamp suture again. The edges of the
fistule came together beautifully, but owing to the indurated condition
on the left side, the corresponding clamp could not be made to embed
itself, and consequently rested on a plane higher than the one on the
opposite side. Notwithstanding this rather unfavorable feature, I was
very sanguine of success. On the thirteenth day, I examined the parts,
and, to my great mortification, saw that the left clamp had again cut
out, and thus enlarged the opening.
After two such signal failures with the only operation that I then
considered worthy of confidence, I was much discouraged, and had
serious thoughts of abandoning the case altogether; but it was only a
week or two subsequently, that the principle of the button suture first
suggested itself to me, and I immediately determined to subject the
case to an experimental trial. All things being ready, on the 12th of
May I put the new method in operation. Everything seemed to pro-
gress favorably. On the thirteenth day, I removed the apparatus, and
to my great delight found the fistule completely closed, and not the
slightest evidence of irritation except what might be naturally expected
around each suture.
Case II.— Two Vesico-Vaginal Fistules of seven months standing; two
operations with the Button Suture; both entirely successful.
Kitty, a colored girl of small stature, aged 18, was sent to me from a
neighboring County, on the 24th of May, 1855. She stated to me that
she always enjoyed good health until the birth of her second child, the
preceding October, with which she was in labor three days; the child
was of large size, and had to be mutilated before delivery could be effected.
She did not discover dribbling of urine until the second week; during
labor and for some time afterward, she had a numb feeling in the lower
extremities; was not able to leave the bed for two months, and even
then could not walk. From that time until she came to me, she sat the
greater portion of her time upon a stool with a hole in it, to allow the
urine to dribble into a vessel placed beneath. Owing probably to the
constancy of that position, sciatica was induced and greatly augmented
her sufferings.
Her appearance, when I first saw her, was the most perfect picture
96
Original Communications.
of misery that I ever beheld; emaciated to such a degree that, her lower
extremities were not larger than chair posts; uuablo to walk or even to
stand; racked with pain; writhing under tho excoriating effect of the un-
controlled urine; with the fatigue of travelling nearly two hundred miles
added; all taken together, rendered her an object of tho most extreme
commiseration. After allowing her to rest for a couple of days, I
made an examination, found her thighs and buttocks extensively ex-
coriated, the labia majora almost completely encrusted by calcareous
matter, and so sensitive, that the least effort to separate thorn, caused
excruciating pain. Before the vagina could he explored, this deposit
had to be removed, and even then the suffering was considerable owing
to an extremely irritable condition of the organ, and a protrusion of
the mucous coat of the bladder through the fistulous opening. When
the speculum was introduced, I discovered that the posterior wall of the
vagina could not be raised up with usual facility. This I soon found
resulted from a morbid attachment of its two walls. The adhesion
extended obliquely across from the right side of the cervix to the left
side of the vagina, thus concealing from view the os uteri, and ren-
dering an exploration of the entire canal impossible. A fistulous
opening, three-quarters of an inch in length, occupied the vesico-vaginal
septum, and extended from near the beginning of the urethra obliquely
upwards and to the left, terminating abruptly at the point of coarcta-
tion. Here a careful examination revealed a small opening which al-
lowed a probe to pass into the cut de sac above, and from thence into
the bladder, showing clearly that another fistule existed in this situa-
tion. Having thus ascertained tho true condition of things, I became
satisfied that two operations would be required. The fistule first
described was accessible, and demanded my first attention, owing to
its larger size and the very irritable state of the mucous coat of the
bladder which protruded through it. I thought it advisable, however,
before attempting any operation, to improve tho patient's general
health. Accordingly she was put upon the use of Precipt. Carb. Iron
three times a day, and confined to bed upon her back," with a catheter
in the urethra, in order to divert the urine from the vagina and exco-
riated parts as much as possible. Under this course of treatment she
very soon began to mend, and not long afterwards could walk about;
which she had not attempted before for months.
June 12th, I proceeded to apply the button suture to tho lower open-
ing. Much difficulty was encountered in paring the edges, owing to
the great resistance of the patient, and the herniated condition of the
mucous coat of the bladder. Four sutures were required; the button
Vesico-Vaginal Fistule. 97
was Jths of an inch in length, and about fths in width. For two or three
days after the operation there was considerable fever, and pain in the
hypogastric region, and I feared something serious might result; but
things soon took a favorable turn, and the case seemed to do well until
about the seventh day. At this time a great discharge of urine oc-
curred from the vagina, and my first impression was that the sutures
had given away; but upon examining the parts carefully, I discovered
the whole of the difficulty to depend upon tympanitic distension
of the bowels, attended at times with powerful peristaltic action. When
the latter would occur, I found that there was a sudden increase in the
flow of urine, clearly resulting from downward pressure upon the blad-
der. To obviate the trouble, I gave several remedies, mostly carmina-
tives; but none of them seemed to be productive of any good. Finally,
I resorted to the use of Turpentine, which answered the purpose
to a very great extent, though not entirely.
Feeling a little uneasiness as to the result, notwithstanding the dis-
covery of tho source of trouble, I determined on the ninth day to re-
move the apparatus. Upon introducing the speculum into the vagina,
the parts presented indeed a most unpromising appearance; the mucous
membrance was of a deep red color, and the button completely en-
crusted with earthy matter. I now had a firm presentiment that
all was not right; but when the sutures were clipped, and the button
raised, I found to my great satisfaction, that union of the parts was
perfect.
The catheter was worn a few days longer, and the patient then al-
lowed to get up. Her general health now improved rapidly, and it was
not long before her sciatica entirely disappeared.
In a few weeks I made preparation for the other operation, by first
breaking up the morbid adhesion between the two walls of the vagina,
so as to expose the fistulous opening above. To prevent reunion of the
parts, a bag, made of oil silk and stuffed with bits of sponge, was in-
troduced into the vagina. This was removed daily, and injections of
cold water used, by which means the upper extremity of the vagina
was in a few weeks dilated to its normal size, and the fistule well ex-
posed.
August 23d, everything appearing as favorable as could be expected,
I proceeded to operate; only three sutures were required; but as in the
former operation, I had much difficulty, owing to the resistance of the
patient. Tympanites supervened again several days after the opera-
tion, and caused the patient a good deal of suffering; but with this ex-
ception the case did well.
98
Original Communications.
On the ninth day I removed the apparatus, and had the satisfaction
of finding an entirely successful result, and not tho slightest irritation
had been produced. The improvement of the patient, in every respect,
was now rapid; and when I discharged her in September, she was as
active and sprightly as though she had never hod a sick day.
Remarks.—The bad health of this patient, the existence of two
fistulous openings, a herniated condition of the mucous coat of the
bladder, a morbid attachment of the two walls of the vagina, and an
exceedingly irritating quality of the urine, were all circumstances which
strongly militated against the treatment. It is indeed one of the most
remarkable cases that has ever come under my observation, and, 1
may add, that a better case for illustrating some of tho advantages
claimed for the button suture, and especially that of protection to the
denuded edges of the fistule from the poisonous effects of the urine,
could not have been selected. After removing tho button employed
in the first operation, its very shape and sizo were found impressed
upon the parts over which it rested during tho healing process, and the
pale red color of the mucous membrane here, contrasted beautifully
with the deep red and fiery appearance of that which had been exposed
to the urine escaping through the upper opening.
Case III.— Two Vesico-Vaginal Fistules of eighteen years standing;
two successful operations with the Button Suture.
Dinah, a colored woman, stout and heavily built, about 47 years of age,
was placed under my charge on the 28th of June, 1855. She stated that
the disease under which she was laboring, was produced by the birth
of her fifth child in 1837. As well as she could recollect, she was in
labor about a day and a half; was attended by a physician, but did
not know whether instruments were employed to effect delivery or not.
Dribbling of the urine commenced a few days afterwards, and in this
condition the poor creature had dragged out eighteen years of miser-
able existence. During this period she miscarried quite a number
of times; only one child having gone to the full time.
Upon examination, I found a fistule near the centre of the vesico-
vaginal septum, circular in shape, and sufficiently large to admit the
index finger into the bladder. Supposing this to be the only opening, on
the 5th of July I applied the button suture. On the tenth day it was
removed, and the parts found to be perfectly united, not the slightest
irritation having been produced by the apparatus. In a few days after-
wards the patient was allowed to get up, but, to my surprise, there was
still dribbling of urine. I apprehended therefore, that the newly form-
Ve8ioo-Vaginal Fistule.
99
ed cicatrix had givan away, and there was a reproduction of the fistule;
but making an examination, I discovered that such was not the case.
I was now at a loss to account for the appearance of urine ; but upon a
more careful exploration of the vagina, I found another very small
opening, situated far up on the right side, at least an inch from the
one I had closed.
The whole difficulty was now explained. Another operation was re-
quired; but, owing to the bad health of the patient, I was not able to
perform it until the 10th of September.
This fistule, although small, had a peculiarity I had never met with
before. It was valvular, i. e. the opening through the vaginal part of
the septum did not correspond to that of the vesical. Two sutures
were sufficient to bring the edges together. Things went on well, and
on the tenth day, I removed the apparatus, and found union perfect.
Remarks.—In this instance the fistulous openings were of eighteen
years standing, the patient old, and her general health not very good;
yet the result was as prompt and decided as could have been desired.
One of the great advantages claimed for the button suture, namely pro-
tection to the denuded edges of the fistule, was again forcibly illustrated
in this case.
Case IV.— Two Vesico- Vaginal Fistules of nine years standing; several
failures with the Clamp Suture; Button Suture employed with entire
success.
The patient, a mulatto girl, aged about 25, of large size, came under
my charge in September 1855. She says that she always enjoyed good
health until the birth of her first child in 1846, at which time she be-
came the subject of her present difficulty. According to her account,
the labor lasted three days, and during that time she passed little or
no urine; does not know whether instruments were employed or not;
discovered very soon afterwards dribbling of urine. She also states,
that she was sent to New Orleans, and there treated for a long time,
with but little if any benefit. Since then she has been operated upon
several times according to the method of Dr. Sims', but the relief af-
forded was only partial.
Upon examination, I found two fistulous openings, one about two
inches from the cervix, and a little to the left side; the other, a little
larger, was, situated far to the right, at a point just where the anterior
and posterior walls of the vagina become continuous.
On the 10th of September, I proceeded to apply the button suture to
the larger opening. It was my intention to close the other also at the
100
Original Communications-
Millie time, but the patient preferred to wait. Only two sutures were
required, and on the tenth day I removed the apparatus, and found
union perfect.
Oetober, tho ISth, I operated upon the other fistule. This I found
presented the same peculiarity that was observed in the preceding
case, in being of a valvular form. Only two sutures were required,
and on the tenth day T removed the apparatus, and found adhesion
perfect, without the slightest irritation in the surrounding parts.
Remarks.—The result in this ease was as satisfactory as could be
desired; it needs no comments. If it proves anything, it is that the
button suture was better adapted to the case than tlie clamp suture,
which latter had been long and perscvoringly tried.
Conclusion.—Having now finished a description of my mode of
treating vesico-vaginal fistule, together with the narration of all the
cases in which it has been employed, I propose, in conclusion, to
compare its results with those obtained by other methods.
Since the l^lh of May last, I have performed seven successive
operations without a single failure. This is the amount of my ex-
perience with the buttou suture. Now to form anything like a
proper estimate of the several modes of treatment heretofore re-
commended, it is necessary first to ascertain what proportion of
the operations according to each have been successful when com-
pared with the whole number performed. In this way only can
their respective merits be properly set forth. To effect this object,
I have examined, so far as my opportunities allowed, the records
both of Europe and this country ; but as the data are imperfect, I
have not been able to arrive at very satisfactory conclusions.
Chelius speaks of Wutzer as having had the greatest success.
Of eighteen cases operated upon, three were radically cured. We
are not informed how many operations were performed in all.
Jobert, by the anaplastic process, cures, I am induced to believe,
about one-half of his cases. What proportion of his operations
fails, I have not been able to learn.
Mr. Henry Earle is said to have operated thirty times upon one
case before succeeding. The failures here were as twenty-nine to
one.
Mr. Brown operated ten times upon three cases, and obtained
one successful result. The failures here were as nine to one.
Vesico-Vaginal Fistule.
101
Dr. Hayward operated twenty times upon nine cases, and ob-
tained three successful results. The failures here were as seven-
teen to three.
I am not prepared to state positively what proportion of the
whole number of operations performed according to the method of
Dr. Sims has been successful. Judging from my own experience,
and from what I have seen of it in the practice of others, I am
inclined to think that the average is not over one-half.
In regard to my own cases, it may be supposed by some that
they were all peculiarly favorable, which accounts for my unpre-
cedented success; but this was not the case: a reference to their
individual histories will show that they were quite the reverse.
The very fact of two of them having resisted the repeated appli-
cation of the clamp suture, is proof sufficient upon this point. The
other two were each double fistules, and therefore very unfavorable.
One of them, case 11,1 consider the most unpromising I have ever
seen, that was at all curable.
In conclusion, I freely acknowledge that the results thus far
obtained, by the use of the button suture, although so remarkably
successful, do not amount to a sufficient number to justify an indis-
putable claim to superiority over all other procedures; and I do
not, therefore, urge its adoption, by the profession, without farther
trial. This is all I ask for it at present. My little experience
with it has led me to believe that the principles upon which it acts
are more nearly correct than any heretofore suggested; but if.
upon more careful examination, this be found not true, it will only
prove that the success of my seven operations was a most remark-
able and heretofore unheard of coincidence,
Montgomery, Jan. 1st, 1856,
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